Internet-Based Surveillance of Vascular Disease and Reconstructions

Introduction

Technology has transformed the delivery of healthcare, both in-person and remotely, over the past 30 years. The World Health Organization (WHO) defines telemedicine (TM) or telehealth (TH) as “The delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities.” This very broad definition of TH includes the use of secure messaging, mobile applications, and telephone and videoconferencing to evaluate new patients preoperatively, follow existing patients after surgery, proctor surgical cases, monitor for changes in electroencephalogram or transcranial doppler during carotid endarterectomy, observe patients for seizure activity, or attend local, regional, and national meetings for continuing medical education, remotely from the comfort of the healthcare provider’s office. We recognize that historically some have used the term “TM” to refer specifically to the diagnosis and treatment of patients by physicians and the broader term “TH” to include all components, activities, and services provided by all healthcare providers including techs, nurses, advanced practice providers (APPs), pharmacists, and physicians using telecommunications technology.

Nowhere does TH have the potential to transform and impact clinical practice as it does in tertiary and quaternary referral centers where patients come from hundreds or even thousands of miles away for treatment by a subject matter expert or subspecialist. TH can extend the availability of these experts to patients in rural communities or those with mobility restrictions or small children. These may be particularly important and valuable in the postoperative setting. In vascular surgery we treat many elderly patients who are at particular risk and may benefit from the opportunity to be followed remotely. TM refers not just to the office consultations we have become so accustomed to during the COVID-19 era, but also to the possibilities that technological evolution has afforded for the assessment of the postoperative cardiovascular patient.

The COVID-19 pandemic has created a monumental surge in the need for our ability to monitor our patients’ recovery from surgery, especially in our high-risk groups with multiple medical comorbidities. The use of TH in vascular surgery specifically is as accurate and effective as on-site evaluations for a variety of vascular problems, including abdominal aortic aneurysms, cerebrovascular disease, and lower extremity occlusive disease. ^, This chapter examines the use of TH in the diagnosis, treatment, and surveillance of the vascular surgery patient.

History of Virtual Medicine

For the first half of the 20th century, telephone was the only platform available for use by clinicians to share health information over long distances. The first radiological images were reportedly sent via the telephone line in the 1940s and shortly thereafter, the National Aeronautics and Space Administration (NASA) was credited with pioneering efforts to develop and pave the way for modern-day telecommunications. Initially concerned about the effects of zero gravity on astronauts, NASA scientists developed ways of monitoring vital signs of astronauts in space as well as diagnosing and treating medical emergencies from the earth as they arose in space.

With the explosion of the internet and world wide web in the 1990s came the ability of healthcare professionals to exchange medical images and information with the click of a mouse. As early as 1993, transcontinental surgical consultations were made possible via the internet. That same year, the American Telemedicine Association was founded with the purpose of accelerating the adoption of TH and ensuring access to safe, effective, and appropriate healthcare by all individuals. Today, with the advancement of mobile and electronic technologies, telemedicine has been made more accessible. Most families have at least one digital device, such as smartphone and webcam, that can provide communication between patient and healthcare provider. In a report by the Pew Research in 2019, 90% of Americans use the internet. In addition, 81% of Americans own a smartphone, nearly 75% own desktop or laptop computers, and roughly 50% own tablet computers or e-readers. These digital devices provide easy accessibility to the internet. With impressive gains in internet speeds and capacity, synchronous telemedicine is now possible via real-time live videos. One of the limitations of telemedicine is physical examination of the patients, although even that is changing rapidly. Recently, remote patient monitoring (RPM) is made possible by the availability of digital stethoscopes, ophthalmoscopes, otoscopes and wearable biosensors for vital signs. RPM has further improved the telemedicine experiences for both patients and providers. In 2016, the Food and Drug Administration (FDA) gave a 510(k) clearance to TytoCare Inc’s digital stethoscope. The company introduced an artificial intelligence (AI) powered diagnostic support solution, providing clinicians with advanced insights for informed remote diagnoses and launched an FDA-cleared fingertip (SpO ₂ ) device that enables users to check blood oxygen saturation levels and heart rate at home. The ability to do this has also been implemented in the National Health Service (NHS) in the United Kingdom, where Arc Health has partnered with the NHS with a similar ability to perform general physical exams with an online tool. Even very accessible applications within the popular smartphones can detect arrhythmias, heart rate and blood pressure, features which can give us important indications of poor postoperative outcomes.

Telehealth Prior to Covid-19

The advancement of electronic technologies and internet speed has led to the rapid increase in the utilization of telemedicine. From 2010 to 2017, there was an increase in the percentage of US hospitals using telemedicine to connect patients from 35% to 76%. Furthermore, the American Medical Association reported that the insurance claims for telemedicine increased by 53% from 2016 to 2017.

Telemedicine is increasingly being used in surgical specialties, and showing promise as part of the solution to an impending provider shortage. The Association of American Medical Colleges projects that there will be a shortage of up to 30,500 surgeons by 2030. It is crucial that surgeons and other physicians find strategies to effectively address this provider shortage and deliver high-quality, convenient care to their patients. In vascular surgery, telemedicine provides equal or superior quality of care compared with traditional in-person consultations for management of varicose veins. Furthermore, these authors also demonstrated high patient satisfaction for virtual vascular clinic with point-of-care ultrasound. A medical staff was present at the satellite locations to obtain the patient’s vital signs. A vascular surgeon interacted with patients via real-time video conferencing, and patients’ information was entered in the electronic medical record. The remote vascular surgeon evaluated the patient via videoconference interview and visual physical examination, reviewed laboratory and imaging results, discussed medical management or surgical intervention, and determined treatment plans with the patient.

Covid-19 Pandemic and Telehealth Evolution

In the US, the Stafford Act, enacted in the middle of March 2020, helped to expedite the adoption of telemedicine. It permitted Medicare & Medicaid Services (CMS) to extend access and reimbursement for telemedicine services. Other US insurers also rapidly expanded medical coverage to include telemedicine and some states waived their licensure requirements for care provided beyond state boundaries. Soon, the American Medical Association (AMA) developed a new resource for physicians to get advice via telemedicine, providing best practices for medical practitioners in adopting a broad range of virtual technologies including telemonitoring, telecare, and telemedicine. These steps helped to transition vascular surgery to internet-based medicine for new outpatient consultations, routine patient surveillances, and postoperative follow-up visits.

The Australian government funded telemedicine services, known as the “Better Access Initiative” program, prior to the COVID-19 pandemic to address the health needs of remote and rural patients during emergency situations such as bushfires and long-term drought. In response to COVID-19, the Australian Government provided extra funded services that allowed for a greater range of telemedicine services to be delivered. Similarly, the United Kingdom’s NHS introduced the adoption of video consultations by health centers to lessen the number of people who visit hospitals and decrease the potential for transmission.

Telehealth technologies have also expanded into other clinical areas. Mobile integrated healthcare programs and community paramedicine have decreased the need for transportation to the emergency department by having physicians provide digital support to patients who call via emergency channels, such as through 911 calls. Mobile health (mHealth) applications using mobile and wearable devices for remote monitoring allow patients to access medical information and physicians to provide support for non-emergency or chronic health problems. Artificial intelligence and machine learning decision-making applications are being used to improve the accuracy of COVID-19 detection and diagnosis. Robotic technologies are being used in China to serve patients in isolation facility or quarantine centers. Health and fitness applications have exploded during this time of social isolation to provide diet plans, calorie counters, and various real-time or pre-recorded follow-along exercise videos.

Natural disasters and epidemics in the past have posed many challenges in providing healthcare. Technological advances have provided new options and innovative solutions to address both the needs of patients with COVID-19 and other people who need healthcare services. Telehealth has provided many benefits that include minimizing the hazard of direct person-to-person exposure, access to healthcare from remote areas, guidance of expert physicians to less experienced medical practitioners, more efficient healthcare during times of workforce reduction and limited resources, disease containment via patient tracking and quarantine, and improved epidemiological research. The COVID-19 pandemic has transformed the care of patients and healthcare delivery around the world in 2020.